復科臨床病例報告二 - 中華民國贋復牙科學會 · 會訊第十八卷 ... op time...

中華民國贋復牙科學會The Academy of Prosthetic Dentistry, Republic of China

會訊第十八卷第四期

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病例討論專欄

復科臨床病例報告二

時間：中華民國一〇三年十二月指導醫師：王東美醫師報告者：林靜芬醫師訓練機構：台大醫院牙科部贋復牙科

█ Personal Data

Name: 林 X 賢Age: 57 y/oGender: maleFinance: goodCooperation : goodMotivation: high　Time factor: fairOccupation: freelance

█ Chief Complaint ● My gum is swollen repeatedly for months. ● I want to restore my teeth for be� er chewing function.

█ Past Dental History ● Operative Dentistry treatment (+) ● Extraction (+) ● Prosthetic treatment : FPD (+); RPD(-) ● Periodontal therapy : Phase I therapy; #13 GTR; #24 resective surgery

█ TMJ Examination ● Limitation of mouth opening (-) ● TMJ palpation pain (-) ● Muscle tenderness (-) ● Clicking or crepitation (-)

█ Personal Habits ● Alcohol drinking (+/-) ● Betel nuts chewing (-) ● Cigare� e smoking (+), had qui� ed ● Parafunction habits (-)

█ Past Medical History ● All major systemic diseases were denied ● No known drug or food allergy



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█ Extroral Findings ● Facial asymmetry(+) mild ● Facial proportion: equal ● Straight pro� le ● Nasolabial angle about 90 degrees

█ Intraoral Findings ● Occlusal analysis

Archform: upper-ovoid; lower-ovoid Overjet: 5.5; overbite:7 Canine relationship: R't- class I; L't- class I Molar relationship: unknown Lateral movement: R't - #14,#44; L't–#23#24,#33#34

● Dental ◆ Multiple missing teeth

◆ Deep overbite and overjet ◆ Lower anterior supra-eruption ◆ Obvious tooth wear ◆ #37 mobility Gr III and furcation involvement ◆ #35,#37,#34, #44,#45,#47 tilting and rotation ◆ #14,#24 elongation

◆ Torus palatinus ◆ Periodontal data(before periodontal treatment)



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█ Panoramic Film

█ Periodontal Examination



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█ Periodontal Prognosis

Tooth 14 13 12 11 21 22 23 24

Probing Depth

334 523 222 222 222 323 322 222

334 723 323 333 534 534 431 533

Recession332 110 011 100 002 221 000 022

211 100 000 000 000 000 000 012

Masticatary Mucosa 4 5 3 3 4 3 4 4

Mobility Ⅰ + + + + + + +

Furcation Inolvement

Tooth 47 45 44 43 42 32 33 34 35 37

Probing Depth

535 334 433 333 334 633 333 433 533 635

335 333 333 323 334 633 434 433 333 310.5

Recession232 233 111 121 001 100 333 000 222 245

333 000 000 010 000 000 000 231 122 135

Masticatary Mucosa 1 1 0 3 4 2 3 0 1 1

Mobility + + + + + + + + Ⅲ

Furcation Inolvement BILI Ⅲ



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病例討論專欄

█ Diagnosis ● Multiple missing teeth

◆ 18,17,16,15,25,26,27,28,38,36,31,41,46,48 ◆ Risk assessment: de� ciency of stable occlusion

● Generalized moderate to severe chronic periodontitis ◆ Etiology: local factor – dental plaque ◆ Predisposing factors: tea-caused stain, intragenic factor, malocclusion, and smoking

● Malocclusion ◆ Risk assessment: di� culty in cleaning access, wear of teeth; dilemma in prosthesis fabrication; de� ciency of

stable occlusion ● A� rition

◆ Etiology: insu� cient posterior support, deep OB and porcelain occlusion

█ Goal of Treatment ● Control of periodontal in� ammatory disease ● Creating a favorable dental env ironment for

maintenance of oral hygiene ● � erapeutic occlusion ● Posterior support build-up ● Shallow of OB and OJ

█ Summary of Intra-Oral Findings ● Multiple missing teeth ● Deep overbite and large overjet ● Lower anterior supra-eruption ● #13~#23 severe tooth wear at cingulum ● #14,#24 supra-eruption and severe tooth wear at palatal side ● #37 mobility Gr III, furcation involvement ● #37,#35,#34, #44,#45,#47 tilting and rotation ● #24,#35 buccal cross-bite ● Torus palatinus

█ Orthodontic intervention ● Curve of spee leveling and overbite decreasing ● Crowding relieving , up-righting and space re-

distribution ● Correcting #24,#35 buccal cross-bite



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█ Cephalometric Film Tracing Analysis

● Skeletal class I with class II tendency ● Low MPA ● upper incisor procline; lower incisor

in norm

█ Treatment Options

● Option 1 with full mouth orthodontic treatment ◆ For maxilla

◆ I15X I17, I25X I27 implantation ◆ For mandible

◆ #37 extraction ◆ I36 I37, I46 implantation ◆ #32x#42 bridge re-fabrication

● Option 2 with lower arch orthodontic treatment ◆ For maxilla

◆ #14,#24 ▲ c r o w n h e i g h t r e d u c t i o n a n d c r o w n

fabrication ▲ intentional RCT may be needed


◆ #37 extraction ◆ I36 I37 , I46 implantation ◆ #32x#42 bridge re-fabrication

● Option 3 without orthodontic treatment ◆ For maxilla

◆ #14,#24 ▲ c r o w n h e i g h t r e d u c t i o n a n d c r o w n

fabrication ▲ intentional RCT may be needed


◆ #37,#35 extraction ◆ I35 XI37 implantation ◆ #32x#42 bridge re-fabrication ◆ #45x#47 ridge or I45 XI47 implantation

● 病人選擇option 2



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█ Periodontal Condition after Phase I Treatment

● 13 Osteoplasty and ostectomy

Tooth 14 13 12 11 21 22 23 24

Probing Depth

B 322 222 222 222 222 222 223 222

P 323 632 222 222 222 222 323 532

Recession332 110 010 101 012 221 010 1222

211 100 001 100 101 111 001 111

Masticatary Mucosa 4 5 3 3 4 3 4 4

Mobility Ⅰ + + + + + + +

Furcation Inolvement

Tooth 47 45 44 43 42 32 33 34 35 37

Probing Depth

B 333 322 323 322 323 323 323 323 333 535

P 333 323 222 322 222 222 222 323 223 3105

Recession222 232 000 221 001 000 333 000 222 256

222 222 000 010 000 110 112 224 122 245

Masticatary Mucosa 1 1 0 3 4 2 3 0 1 1

Mobility + + + + + + + + Ⅲ

Furcation Inolvement BILI Ⅲ



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█ Model Surgery & Diagnostic Wax-up

█ Surgical Stent Fabrication

█ Post Model Surgery Position Change (mm)

Tooth 47 45 44 43 42 32 33 34 35

Vertical -2.5 2.5 2 -0.5 -4 -4 -3.5 0.5 -2

M-D M1.5 M0.5

3-3 4-4 5-5

Transverse Change 0 +3 +5

● 由於上顎位置不變，利用c r o s s mount將diagnostic wax up的結果在牙齒未改變位置的initial cast上做成surgical stent。



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█ CBCT-Maxilla

#17

#15

#16



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#25

#26

#27

█ CBCT-Mandible



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#36

#37

#46



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█ Defi nitive Treatment Plan

█ Working Cast

● lower arch orthodontic treatment ● #37 extraction ● #14,#24

◆ crown height reduction and crown fabrication ◆ intentional RCT may be needed

● I15x I17, I25 I26 , I36 I37 , I46 implantation ● #32x#42 bridge re-fabrication

█ Implant Placement-Astra tech OsseoSpeed

Implant I17 I15 I25 I26 I36 I37 I46

Width(mm) 5.0 4.0s 4.5 4.5 4.5 4.5 5.0

Length(mm) 9 11 9 9 9 9 11

OP time 201110.28

201110.28

201111.24

201111.24

201202.03

201202.03

201212.30



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█ Before ortho tx 2012.05.24

█ Mid-tx: 2 month 2012.07.31



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█ Mid-tx: 4 Month 2012.09.26

█ Ortho Tx Completed: 13 Month 2013.06.27



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█ Orthodontic Treatment Course █ Post Ortho Cepa Analysis

● Mandible順時針旋轉● Lower anterior往前� are● Overbite的減少與mandible的旋轉導致SN-OP明顯增加

Impression, cross-mounting, wax-up for I15xI17;I46 screw-retained prosthesis



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Impression, cross-mounting, wax-up for I15xI17;I46 screw-retained prosthesis

32x42 e.max press monolithic bridge

█ Deliver

Occlusal view



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MI

Protrusive and lateral excurtion

█ Pre-treatment 2011.02.14



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█ Post-treatment 2013.12.17



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病例討論專欄

Q2： 13為periodontal compromised tooth，以13作為主要側向運動的引導有何考量？

A2：側向運動時，主要是1314與2324做為引導的牙齒。主要原因是因為後方為植牙贋復物，所以希望側向移動時可以避開植牙，減少對植牙的側向力量。雖然13牙周在治療前不佳，但GTR後，angular bony defect已獲得改善，並且在provisional stage沒有再產生mobility, bony defect, pocket等問題，所以決定側向移動時，以1314作為右側主要引導牙齒。可以考慮1314 splinting，但是1314均為自然未做贋復物的牙齒，做crown splinting太可惜，使用resin, wire也擔心病人如果清潔不善，更容易有牙周破壞。況且，此時centric occlusion後方有足夠的支撐，相對於治療前，對於前牙的loading的減少是有幫助的。所以決定不將1314 splinting。

Q1：病人重建後的occlusal scheme為何？

A1：在centric occlusion為所有牙齒均勻碰到；在前凸運動時，為前牙一致碰到；側向移動時，為兩側的

1314及2324與下牙的4344及3334作為引導，後牙沒有碰到，減少後牙的植牙在側向運動時的側向

力。



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Q3：為何對照治療前後cephalometric analysis，可以發現mandible的前緣沒有變

化，但後緣卻往下移？

A3：應該是來自cephalometry照相或是製圖的誤差。

Q4：病人為anterior deep overbite，矯正前期需墊高VD進行治療，但對於periodontal compromisedteeth，是否會擔心對於periodontal support更加不利？

A4：雖然提高VD，但是病人剩下的多為前牙，所以posterior support的建立(植牙)及overbite的減少對於剩下periodontal compromised的牙齒反而可以減少loading。

Q5：病人在進行矯正治療時，為何下顎32x42 bridge並沒有分開，而是以temporary bridge連在一起，結果似乎32x42的牙齒看起來比較大？

A5：一開始便決定以3 incisors重建下顎，主要是因為計算bolton's ratio，原本的3 incisors大小剛好可以達到後牙class I occlusion，但原本的空間並無法容納4顆正常大小的incisors，所以一開始便決定以3 incisors重建。矯正過程中，將32, 42以temporary bridge相連，主要為矯正科醫師認為還是有把握進行治療，但如果32, 42分開，缺牙的空間必須多做一個pontic以矯正器固定在wire上維持空間，容易造成清潔的死角，所以希望我們還是以bridge方式作為temporary prosthesis。

復科臨床病例報告二 - 中華民國贋復牙科學會 · 會訊 第十八卷 ... op time...

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復科臨床病例報告二 - 中華民國贋復牙科學會 · 會訊第十八卷 ... op time...